Current Psychiatry

Mr. L, age 35, has an appointment at a mental health clinic for ongo­ing treatment of depression. His medication list includes atorvastatin, bupro­pion, lisinopril, and cranberry capsules for non-descriptive urinary issues. He has been treated for some time at a different outpa­tient facility; however he recently moved and changed clinics.

At this visit, his first, Mr. L receives a full physical exam, including a urine drug screen point-of-care (POC) test. He informs the nurse that he has an extensive history of drug abuse: “You name it, I’ve done it.” Although he experimented with many illicit substances, he acknowledges that “down­ers” were his favorite. He believes that his drug abuse could have caused his depres­sion, but is proud to declare that he has been “clean” for 12 months and his depression is approaching remission.

However, the urine drug screen is positive for amphetamines. Mr. L vehemently swears that the test must be wrong, restating that he has been clean for 12 months. “Besides, I don’t even like ‘uppers’!” Because of Mr. L’s insistence, the clinician does a brief literature search about false-positive results in urine drug screening, which shows that, rarely, bupropion can trigger a false positive in the amphetamine immunoassay.

Could this be a false-positive result? Or is Mr. L not telling the truth?

Because no clinical lab test is perfect, any clinician who runs urine drug screens will encounter a false-positive result. (See the Box,^1-3 for discussion of false negatives.) Understanding how each test works—and potential sources of error— can help you evaluate test results and determine the best course of action.

In-office urine testing
POC tests in urine drug screens use a tech­nique called “immunoassay,” which is quantitative and generally will detect the agent in urine for only 3 to 7 days after ingestion.⁴ This test relies on the principle of competitive binding: If a parent drug or metabolite is present in urine, it will bind to a specific antibody site on the test strip and produce a positive result.⁵ Other compounds that are similarly “shaped” on a molecular level also can bind to these antibody sites when present in sufficient quantity, producing a “cross reaction,” also called a “false-positive” result. The Table⁶ lists agents that can cross-react with immu­noassay tests. In addition to the cross-reaction, false positives also can occur because of technician or clerical error— making it important to review the process by which the specimen was obtained and tested if a false-positive result is suspected, as in the case described here.⁷

Different POC tests can have vary­ing cross-reactivity patterns, based on the antibody used.⁸ In general, false positives in immunoassays are rare, but amphetamine and opiate false posi­tives are more common than cocaine metabolite and cannabinoid false posi­tives.⁹ The odds of a false positive vary, depending on the specificity of the immunoassay used and the substance under detection.⁶

A study that analyzed 10,000 POC urine drug screens found that 362 speci­mens tested positive for amphetamines, but that 128 of those did not test posi­tive for amphetamines using more sensitive tests.¹⁰ Of these 128 false posi­tives reported, 53 patients were tak­ing bupropion at the time of the test.¹⁰ Therefore, clinicians should do a thor­ough patient medication review at the time of POC urine drug testing. In addi­tion, consider identifying which type of test you are using at your practice site, and ask the manufacturer or lab to provide a list of known possible false positives.

Laboratory-based GC–MS testing
If a false positive is suspected on a POC immunoassay-based urine drug screen, results can be confirmed using gas chromatography–mass spectrometry (GC–MS). Although GC–MS is more accu­rate than an immunoassay, it also is more expensive and time-consuming.⁹

GC–MS breaks down a specimen into ionized fragments and separates them based on their mass–charge ratio. Because of this, GC–MS is able to identify the presence of a specific drug (eg, oxyco­done) instead of a broad class (eg, opi­oid). The GC–MS method is a good tool to confirm initial positive screens when their integrity is in question because, unlike POC tests used during an office visit, GC–MS is not influenced by cross-reacting compounds.^11-13

GC–MS is not error-free, however. For example, heroin and hydrocodone are metabolized into morphine and hydro­morphone, respectively. Depending on when the specimen was collected, the metabolites, not the parents, might be the compounds identified, which might pro­duce confusing results.

Clinical recommendations
When a POC drug screen is positive, con­firming the result with GC–MS is good clinical practice. False positives can strain the relationship between patient and pro­vider, thus compromising care. Examining the procedures that were used to obtain the specimen, as well as double-checking POC test results, is, when appropriate, good medicine.

CASE CONTINUED
Because Mr. L is adamant about his sobriety and the fact that his drugs of choice were sedatives, not stimulants, the clinician orders a second drug screen by GC–MS. The second screen is negative for substances of abuse; Mr. L’s clinician concludes that bupropion pro­duced a false-positive result on the POC urine drug screen, confirming Mr. L’s assertions.

Related Resources
• Saitman A, Park HD, Fitzgerald RL. False-positive interferences of common urine drug screen immunoas­says: a review. J Anal Toxicol. 2014;38(7):387-396.
• Tenore PL. Advanced urine toxicology testing. J Addict Dis. 2010;29(4):436-448.

Drug Brand Names
Amantadine • Symadine, Symmetrel
Amitriptyline • Elavil
Atorvastatin • Lipitor
Brompheniramine • Dimetane
Bupropion • Wellbutrin, Zyban
Carbamazepine • Carbatrol, Tegretol
Chlorpromazine • Thorazine
Clomipramine • Anafranil
Cyclobenzaprine • Amrix, Flexeril
Cyproheptadine • Periactin
Desipramine • Nopramin
Desoxyephedrine • Desoxyn
Dextromethorphan • Delsym, Robitussin
Dicyclomine • Bentyl, Dicyclocot
Diphenhydramine • Benadryl, Unisom
Doxylamine • Robitussin, NyQuil
Dronabinol • Marinol
Efavirenz • Sustiva
Ephedrine • Mistol, Va-Tro-Nol
Ergotamine • Ergomar, Cafergot
Hydrocodone • Vicodin
Hydromophone • Dilaudid, Palladone
Hydroxyzine • Atarax, Vistaril
Isometheptene • Amidrine, Migrend
Isoxsuprine • Vasodilan, Vasoprine
Ketoprofen • Orudis, Oruvail
Labetalol • Normodyne, Trandate
Lisinopril • Prinivil, Zestril
Meperidine • Demerol
Naproxen • Aleve, Naprosyn
Oxaprozin • Daypro
Oxycodone • Oxycontin, Percocet, Percodan, Roxicodone
Phentermine • Adipex, Phentrol
Phenylephrine • Sudafed PE, Neo-Synephrine
Piroxicam • Feldene
Promethazine • Phenergan
Pseudoephedrine • Sudafed, Dimetapp
Quetiapine • Seroquel
Ranitidine • Zantac
Rifampin • Rifadin, Rimactane
Selegiline • EMSAM
Sertraline • Zoloft
Sulindac • Clinoril
Sumatriptan • Imitrex
Thioridazine • Mellaril
Tolmetin • Tolectin
Trazodone • Desyrel, Oleptro
Trimethobenzamide • Benzacot, Tigan
Trimipramine • Surmontil
Verapamil • Calan, Isoptin

Mr. L, age 35, has an appointment at a mental health clinic for ongo­ing treatment of depression. His medication list includes atorvastatin, bupro­pion, lisinopril, and cranberry capsules for non-descriptive urinary issues. He has been treated for some time at a different outpa­tient facility; however he recently moved and changed clinics.

At this visit, his first, Mr. L receives a full physical exam, including a urine drug screen point-of-care (POC) test. He informs the nurse that he has an extensive history of drug abuse: “You name it, I’ve done it.” Although he experimented with many illicit substances, he acknowledges that “down­ers” were his favorite. He believes that his drug abuse could have caused his depres­sion, but is proud to declare that he has been “clean” for 12 months and his depression is approaching remission.

However, the urine drug screen is positive for amphetamines. Mr. L vehemently swears that the test must be wrong, restating that he has been clean for 12 months. “Besides, I don’t even like ‘uppers’!” Because of Mr. L’s insistence, the clinician does a brief literature search about false-positive results in urine drug screening, which shows that, rarely, bupropion can trigger a false positive in the amphetamine immunoassay.

Could this be a false-positive result? Or is Mr. L not telling the truth?

Because no clinical lab test is perfect, any clinician who runs urine drug screens will encounter a false-positive result. (See the Box,^1-3 for discussion of false negatives.) Understanding how each test works—and potential sources of error— can help you evaluate test results and determine the best course of action.

In-office urine testing
POC tests in urine drug screens use a tech­nique called “immunoassay,” which is quantitative and generally will detect the agent in urine for only 3 to 7 days after ingestion.⁴ This test relies on the principle of competitive binding: If a parent drug or metabolite is present in urine, it will bind to a specific antibody site on the test strip and produce a positive result.⁵ Other compounds that are similarly “shaped” on a molecular level also can bind to these antibody sites when present in sufficient quantity, producing a “cross reaction,” also called a “false-positive” result. The Table⁶ lists agents that can cross-react with immu­noassay tests. In addition to the cross-reaction, false positives also can occur because of technician or clerical error— making it important to review the process by which the specimen was obtained and tested if a false-positive result is suspected, as in the case described here.⁷

Different POC tests can have vary­ing cross-reactivity patterns, based on the antibody used.⁸ In general, false positives in immunoassays are rare, but amphetamine and opiate false posi­tives are more common than cocaine metabolite and cannabinoid false posi­tives.⁹ The odds of a false positive vary, depending on the specificity of the immunoassay used and the substance under detection.⁶

A study that analyzed 10,000 POC urine drug screens found that 362 speci­mens tested positive for amphetamines, but that 128 of those did not test posi­tive for amphetamines using more sensitive tests.¹⁰ Of these 128 false posi­tives reported, 53 patients were tak­ing bupropion at the time of the test.¹⁰ Therefore, clinicians should do a thor­ough patient medication review at the time of POC urine drug testing. In addi­tion, consider identifying which type of test you are using at your practice site, and ask the manufacturer or lab to provide a list of known possible false positives.

Laboratory-based GC–MS testing
If a false positive is suspected on a POC immunoassay-based urine drug screen, results can be confirmed using gas chromatography–mass spectrometry (GC–MS). Although GC–MS is more accu­rate than an immunoassay, it also is more expensive and time-consuming.⁹

GC–MS breaks down a specimen into ionized fragments and separates them based on their mass–charge ratio. Because of this, GC–MS is able to identify the presence of a specific drug (eg, oxyco­done) instead of a broad class (eg, opi­oid). The GC–MS method is a good tool to confirm initial positive screens when their integrity is in question because, unlike POC tests used during an office visit, GC–MS is not influenced by cross-reacting compounds.^11-13

GC–MS is not error-free, however. For example, heroin and hydrocodone are metabolized into morphine and hydro­morphone, respectively. Depending on when the specimen was collected, the metabolites, not the parents, might be the compounds identified, which might pro­duce confusing results.

Clinical recommendations
When a POC drug screen is positive, con­firming the result with GC–MS is good clinical practice. False positives can strain the relationship between patient and pro­vider, thus compromising care. Examining the procedures that were used to obtain the specimen, as well as double-checking POC test results, is, when appropriate, good medicine.

CASE CONTINUED
Because Mr. L is adamant about his sobriety and the fact that his drugs of choice were sedatives, not stimulants, the clinician orders a second drug screen by GC–MS. The second screen is negative for substances of abuse; Mr. L’s clinician concludes that bupropion pro­duced a false-positive result on the POC urine drug screen, confirming Mr. L’s assertions.

Related Resources
• Saitman A, Park HD, Fitzgerald RL. False-positive interferences of common urine drug screen immunoas­says: a review. J Anal Toxicol. 2014;38(7):387-396.
• Tenore PL. Advanced urine toxicology testing. J Addict Dis. 2010;29(4):436-448.

Drug Brand Names
Amantadine • Symadine, Symmetrel
Amitriptyline • Elavil
Atorvastatin • Lipitor
Brompheniramine • Dimetane
Bupropion • Wellbutrin, Zyban
Carbamazepine • Carbatrol, Tegretol
Chlorpromazine • Thorazine
Clomipramine • Anafranil
Cyclobenzaprine • Amrix, Flexeril
Cyproheptadine • Periactin
Desipramine • Nopramin
Desoxyephedrine • Desoxyn
Dextromethorphan • Delsym, Robitussin
Dicyclomine • Bentyl, Dicyclocot
Diphenhydramine • Benadryl, Unisom
Doxylamine • Robitussin, NyQuil
Dronabinol • Marinol
Efavirenz • Sustiva
Ephedrine • Mistol, Va-Tro-Nol
Ergotamine • Ergomar, Cafergot
Hydrocodone • Vicodin
Hydromophone • Dilaudid, Palladone
Hydroxyzine • Atarax, Vistaril
Isometheptene • Amidrine, Migrend
Isoxsuprine • Vasodilan, Vasoprine
Ketoprofen • Orudis, Oruvail
Labetalol • Normodyne, Trandate
Lisinopril • Prinivil, Zestril
Meperidine • Demerol
Naproxen • Aleve, Naprosyn
Oxaprozin • Daypro
Oxycodone • Oxycontin, Percocet, Percodan, Roxicodone
Phentermine • Adipex, Phentrol
Phenylephrine • Sudafed PE, Neo-Synephrine
Piroxicam • Feldene
Promethazine • Phenergan
Pseudoephedrine • Sudafed, Dimetapp
Quetiapine • Seroquel
Ranitidine • Zantac
Rifampin • Rifadin, Rimactane
Selegiline • EMSAM
Sertraline • Zoloft
Sulindac • Clinoril
Sumatriptan • Imitrex
Thioridazine • Mellaril
Tolmetin • Tolectin
Trazodone • Desyrel, Oleptro
Trimethobenzamide • Benzacot, Tigan
Trimipramine • Surmontil
Verapamil • Calan, Isoptin

Mr. L, age 35, has an appointment at a mental health clinic for ongo­ing treatment of depression. His medication list includes atorvastatin, bupro­pion, lisinopril, and cranberry capsules for non-descriptive urinary issues. He has been treated for some time at a different outpa­tient facility; however he recently moved and changed clinics.

At this visit, his first, Mr. L receives a full physical exam, including a urine drug screen point-of-care (POC) test. He informs the nurse that he has an extensive history of drug abuse: “You name it, I’ve done it.” Although he experimented with many illicit substances, he acknowledges that “down­ers” were his favorite. He believes that his drug abuse could have caused his depres­sion, but is proud to declare that he has been “clean” for 12 months and his depression is approaching remission.

However, the urine drug screen is positive for amphetamines. Mr. L vehemently swears that the test must be wrong, restating that he has been clean for 12 months. “Besides, I don’t even like ‘uppers’!” Because of Mr. L’s insistence, the clinician does a brief literature search about false-positive results in urine drug screening, which shows that, rarely, bupropion can trigger a false positive in the amphetamine immunoassay.

Could this be a false-positive result? Or is Mr. L not telling the truth?

Because no clinical lab test is perfect, any clinician who runs urine drug screens will encounter a false-positive result. (See the Box,^1-3 for discussion of false negatives.) Understanding how each test works—and potential sources of error— can help you evaluate test results and determine the best course of action.

In-office urine testing
POC tests in urine drug screens use a tech­nique called “immunoassay,” which is quantitative and generally will detect the agent in urine for only 3 to 7 days after ingestion.⁴ This test relies on the principle of competitive binding: If a parent drug or metabolite is present in urine, it will bind to a specific antibody site on the test strip and produce a positive result.⁵ Other compounds that are similarly “shaped” on a molecular level also can bind to these antibody sites when present in sufficient quantity, producing a “cross reaction,” also called a “false-positive” result. The Table⁶ lists agents that can cross-react with immu­noassay tests. In addition to the cross-reaction, false positives also can occur because of technician or clerical error— making it important to review the process by which the specimen was obtained and tested if a false-positive result is suspected, as in the case described here.⁷

Different POC tests can have vary­ing cross-reactivity patterns, based on the antibody used.⁸ In general, false positives in immunoassays are rare, but amphetamine and opiate false posi­tives are more common than cocaine metabolite and cannabinoid false posi­tives.⁹ The odds of a false positive vary, depending on the specificity of the immunoassay used and the substance under detection.⁶

A study that analyzed 10,000 POC urine drug screens found that 362 speci­mens tested positive for amphetamines, but that 128 of those did not test posi­tive for amphetamines using more sensitive tests.¹⁰ Of these 128 false posi­tives reported, 53 patients were tak­ing bupropion at the time of the test.¹⁰ Therefore, clinicians should do a thor­ough patient medication review at the time of POC urine drug testing. In addi­tion, consider identifying which type of test you are using at your practice site, and ask the manufacturer or lab to provide a list of known possible false positives.

Laboratory-based GC–MS testing
If a false positive is suspected on a POC immunoassay-based urine drug screen, results can be confirmed using gas chromatography–mass spectrometry (GC–MS). Although GC–MS is more accu­rate than an immunoassay, it also is more expensive and time-consuming.⁹

GC–MS breaks down a specimen into ionized fragments and separates them based on their mass–charge ratio. Because of this, GC–MS is able to identify the presence of a specific drug (eg, oxyco­done) instead of a broad class (eg, opi­oid). The GC–MS method is a good tool to confirm initial positive screens when their integrity is in question because, unlike POC tests used during an office visit, GC–MS is not influenced by cross-reacting compounds.^11-13

GC–MS is not error-free, however. For example, heroin and hydrocodone are metabolized into morphine and hydro­morphone, respectively. Depending on when the specimen was collected, the metabolites, not the parents, might be the compounds identified, which might pro­duce confusing results.

Clinical recommendations
When a POC drug screen is positive, con­firming the result with GC–MS is good clinical practice. False positives can strain the relationship between patient and pro­vider, thus compromising care. Examining the procedures that were used to obtain the specimen, as well as double-checking POC test results, is, when appropriate, good medicine.

CASE CONTINUED
Because Mr. L is adamant about his sobriety and the fact that his drugs of choice were sedatives, not stimulants, the clinician orders a second drug screen by GC–MS. The second screen is negative for substances of abuse; Mr. L’s clinician concludes that bupropion pro­duced a false-positive result on the POC urine drug screen, confirming Mr. L’s assertions.

Related Resources
• Saitman A, Park HD, Fitzgerald RL. False-positive interferences of common urine drug screen immunoas­says: a review. J Anal Toxicol. 2014;38(7):387-396.
• Tenore PL. Advanced urine toxicology testing. J Addict Dis. 2010;29(4):436-448.

Drug Brand Names
Amantadine • Symadine, Symmetrel
Amitriptyline • Elavil
Atorvastatin • Lipitor
Brompheniramine • Dimetane
Bupropion • Wellbutrin, Zyban
Carbamazepine • Carbatrol, Tegretol
Chlorpromazine • Thorazine
Clomipramine • Anafranil
Cyclobenzaprine • Amrix, Flexeril
Cyproheptadine • Periactin
Desipramine • Nopramin
Desoxyephedrine • Desoxyn
Dextromethorphan • Delsym, Robitussin
Dicyclomine • Bentyl, Dicyclocot
Diphenhydramine • Benadryl, Unisom
Doxylamine • Robitussin, NyQuil
Dronabinol • Marinol
Efavirenz • Sustiva
Ephedrine • Mistol, Va-Tro-Nol
Ergotamine • Ergomar, Cafergot
Hydrocodone • Vicodin
Hydromophone • Dilaudid, Palladone
Hydroxyzine • Atarax, Vistaril
Isometheptene • Amidrine, Migrend
Isoxsuprine • Vasodilan, Vasoprine
Ketoprofen • Orudis, Oruvail
Labetalol • Normodyne, Trandate
Lisinopril • Prinivil, Zestril
Meperidine • Demerol
Naproxen • Aleve, Naprosyn
Oxaprozin • Daypro
Oxycodone • Oxycontin, Percocet, Percodan, Roxicodone
Phentermine • Adipex, Phentrol
Phenylephrine • Sudafed PE, Neo-Synephrine
Piroxicam • Feldene
Promethazine • Phenergan
Pseudoephedrine • Sudafed, Dimetapp
Quetiapine • Seroquel
Ranitidine • Zantac
Rifampin • Rifadin, Rimactane
Selegiline • EMSAM
Sertraline • Zoloft
Sulindac • Clinoril
Sumatriptan • Imitrex
Thioridazine • Mellaril
Tolmetin • Tolectin
Trazodone • Desyrel, Oleptro
Trimethobenzamide • Benzacot, Tigan
Trimipramine • Surmontil
Verapamil • Calan, Isoptin

Consider stroke. Guidelines for acute treatment, access, intervention, pre­vention of post-hospitalization relapse, and rehabilitation are extensively spelled out and implemented.¹ (The Box outlines Mayo Clinic guidelines for stroke management, as a demonstration of the comprehensive­ness of the approach.)

Schizophrenia and related severe mental illnesses (SMI) need a similar all-inclusive system that seamlessly provides the myriad components of care needed for this vulnerable population. I propose the term “therapeutic placenta” to describe what people with a dis­abling SMI brain disorder deserve, just as stroke patients do.

Closing asylums: Psychosocial abruptio placentae
In a past Editorial,² I described the appalling consequences of eliminat­ing the asylum, an entity that I believe must be a key component of the SMI therapeutic placenta. The asylum is to schizophrenia as the skilled nurs­ing home is to stroke. SMI patients suffered extensively when asylums were shut down; they lost a medical refuge with psychiatric and primary care, nursing and social work sup­port, occupational and recreational therapies, and work therapy (farming, carpentry shop, cafeteria, laundry, etc.). For SMI, these services are the psychosocial counterpart of various physical rehabilitation therapies for stroke patients that no one would ever dare to eliminate.

Persons with schizophrenia and other SMI have suffered tragically with rupture of the main compo­nents of the therapeutic placenta that existed for decades before the advent of medications. The massive home­lessness, widespread incarceration, persistent poverty, rampant access to alcohol and drugs of abuse, early death due to lack of primary care, and absence of meaningful opportu­nities for vocational rehabilitation are all consequences of a neglectful soci­ety that refuses to fund a therapeutic placenta for the SMI population.

The public mental health system in charge of SMI patients is broken, disconnected, and failing to provide the necessary components of a therapeutic placenta. It should not be surprising to witness the terribly stressful life and premature mortality of SMI patients, who are modern-day les misérables.

The Table lists what I consider to be the necessary spectrum of health care services through the life of an SMI patient that an optimal therapeutic pla­centa must provide until an effective pre­vention or a cure for SMI is discovered.

Reasons to be hopeful
Admittedly, encouraging steps are being made toward establishing a therapeutic placenta for SMI:

The RAISE Study³and Navigate Program⁴ demonstrate that implement­ing a comprehensive program of acute treatment and psychosocial interven­tions and rehabilitation yields better outcomes in SMI.

The Institute of Medicine released a landmark report on psychosocial interventions for mental illness and substance abuse disorders. It outlines a new model for establishing the effec­tiveness of intervention and the imple­mentation of psychosocial strategies in clinical practice.⁵

The 21st Century Cures Act, if passed by Congress and signed by the President, will increase funding for the National Institutes of Health, which in turn will bolster the budgets of the National Institute of Mental Health, National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism and enhance the chances of discovering better treatments and prevention of SMI. 

The Helping Families in Mental Health Crisis Act, more directly relevant to men­tal health and psychiatry, proposes, if passed, to:
   • enhance evidence-based and sci­entifically validated interventions in the public sector
   • raise the profile of mental health within the federal government by creat­ing a position of Assistant Secretary for Mental Health in the U.S. Department of Health and Human Services, who will have oversight of both research and mental health care within the fed­eral government.

Unacceptable disparity must be remedied
Planning an effective therapeutic pla­centa is imperative if health care for SMI patients is to approach the comprehen­sive spectrum of treatment, rehabilita­tion, and prevention available to stroke patients. Although stroke is regarded as a sensory-motor brain disorder, it is also associated with mental symp­toms, just as schizophrenia is associ­ated with sensory-motor symptoms. Both are disabling brain disorders: one, physically and cognitively; the other, mentally and socially. Both require a therapeutic placenta: Stroke is sup­ported by one; schizophrenia is not. This is an unacceptable disparity that must be addressed—soon.

Consider stroke. Guidelines for acute treatment, access, intervention, pre­vention of post-hospitalization relapse, and rehabilitation are extensively spelled out and implemented.¹ (The Box outlines Mayo Clinic guidelines for stroke management, as a demonstration of the comprehensive­ness of the approach.)

Schizophrenia and related severe mental illnesses (SMI) need a similar all-inclusive system that seamlessly provides the myriad components of care needed for this vulnerable population. I propose the term “therapeutic placenta” to describe what people with a dis­abling SMI brain disorder deserve, just as stroke patients do.

Closing asylums: Psychosocial abruptio placentae
In a past Editorial,² I described the appalling consequences of eliminat­ing the asylum, an entity that I believe must be a key component of the SMI therapeutic placenta. The asylum is to schizophrenia as the skilled nurs­ing home is to stroke. SMI patients suffered extensively when asylums were shut down; they lost a medical refuge with psychiatric and primary care, nursing and social work sup­port, occupational and recreational therapies, and work therapy (farming, carpentry shop, cafeteria, laundry, etc.). For SMI, these services are the psychosocial counterpart of various physical rehabilitation therapies for stroke patients that no one would ever dare to eliminate.

Persons with schizophrenia and other SMI have suffered tragically with rupture of the main compo­nents of the therapeutic placenta that existed for decades before the advent of medications. The massive home­lessness, widespread incarceration, persistent poverty, rampant access to alcohol and drugs of abuse, early death due to lack of primary care, and absence of meaningful opportu­nities for vocational rehabilitation are all consequences of a neglectful soci­ety that refuses to fund a therapeutic placenta for the SMI population.

The public mental health system in charge of SMI patients is broken, disconnected, and failing to provide the necessary components of a therapeutic placenta. It should not be surprising to witness the terribly stressful life and premature mortality of SMI patients, who are modern-day les misérables.

The Table lists what I consider to be the necessary spectrum of health care services through the life of an SMI patient that an optimal therapeutic pla­centa must provide until an effective pre­vention or a cure for SMI is discovered.

Reasons to be hopeful
Admittedly, encouraging steps are being made toward establishing a therapeutic placenta for SMI:

The RAISE Study³and Navigate Program⁴ demonstrate that implement­ing a comprehensive program of acute treatment and psychosocial interven­tions and rehabilitation yields better outcomes in SMI.

The Institute of Medicine released a landmark report on psychosocial interventions for mental illness and substance abuse disorders. It outlines a new model for establishing the effec­tiveness of intervention and the imple­mentation of psychosocial strategies in clinical practice.⁵

The 21st Century Cures Act, if passed by Congress and signed by the President, will increase funding for the National Institutes of Health, which in turn will bolster the budgets of the National Institute of Mental Health, National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism and enhance the chances of discovering better treatments and prevention of SMI. 

The Helping Families in Mental Health Crisis Act, more directly relevant to men­tal health and psychiatry, proposes, if passed, to:
   • enhance evidence-based and sci­entifically validated interventions in the public sector
   • raise the profile of mental health within the federal government by creat­ing a position of Assistant Secretary for Mental Health in the U.S. Department of Health and Human Services, who will have oversight of both research and mental health care within the fed­eral government.

Unacceptable disparity must be remedied
Planning an effective therapeutic pla­centa is imperative if health care for SMI patients is to approach the comprehen­sive spectrum of treatment, rehabilita­tion, and prevention available to stroke patients. Although stroke is regarded as a sensory-motor brain disorder, it is also associated with mental symp­toms, just as schizophrenia is associ­ated with sensory-motor symptoms. Both are disabling brain disorders: one, physically and cognitively; the other, mentally and socially. Both require a therapeutic placenta: Stroke is sup­ported by one; schizophrenia is not. This is an unacceptable disparity that must be addressed—soon.

Consider stroke. Guidelines for acute treatment, access, intervention, pre­vention of post-hospitalization relapse, and rehabilitation are extensively spelled out and implemented.¹ (The Box outlines Mayo Clinic guidelines for stroke management, as a demonstration of the comprehensive­ness of the approach.)

Schizophrenia and related severe mental illnesses (SMI) need a similar all-inclusive system that seamlessly provides the myriad components of care needed for this vulnerable population. I propose the term “therapeutic placenta” to describe what people with a dis­abling SMI brain disorder deserve, just as stroke patients do.

Closing asylums: Psychosocial abruptio placentae
In a past Editorial,² I described the appalling consequences of eliminat­ing the asylum, an entity that I believe must be a key component of the SMI therapeutic placenta. The asylum is to schizophrenia as the skilled nurs­ing home is to stroke. SMI patients suffered extensively when asylums were shut down; they lost a medical refuge with psychiatric and primary care, nursing and social work sup­port, occupational and recreational therapies, and work therapy (farming, carpentry shop, cafeteria, laundry, etc.). For SMI, these services are the psychosocial counterpart of various physical rehabilitation therapies for stroke patients that no one would ever dare to eliminate.

Persons with schizophrenia and other SMI have suffered tragically with rupture of the main compo­nents of the therapeutic placenta that existed for decades before the advent of medications. The massive home­lessness, widespread incarceration, persistent poverty, rampant access to alcohol and drugs of abuse, early death due to lack of primary care, and absence of meaningful opportu­nities for vocational rehabilitation are all consequences of a neglectful soci­ety that refuses to fund a therapeutic placenta for the SMI population.

The public mental health system in charge of SMI patients is broken, disconnected, and failing to provide the necessary components of a therapeutic placenta. It should not be surprising to witness the terribly stressful life and premature mortality of SMI patients, who are modern-day les misérables.

The Table lists what I consider to be the necessary spectrum of health care services through the life of an SMI patient that an optimal therapeutic pla­centa must provide until an effective pre­vention or a cure for SMI is discovered.

Reasons to be hopeful
Admittedly, encouraging steps are being made toward establishing a therapeutic placenta for SMI:

The RAISE Study³and Navigate Program⁴ demonstrate that implement­ing a comprehensive program of acute treatment and psychosocial interven­tions and rehabilitation yields better outcomes in SMI.

The Institute of Medicine released a landmark report on psychosocial interventions for mental illness and substance abuse disorders. It outlines a new model for establishing the effec­tiveness of intervention and the imple­mentation of psychosocial strategies in clinical practice.⁵

The 21st Century Cures Act, if passed by Congress and signed by the President, will increase funding for the National Institutes of Health, which in turn will bolster the budgets of the National Institute of Mental Health, National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism and enhance the chances of discovering better treatments and prevention of SMI. 

The Helping Families in Mental Health Crisis Act, more directly relevant to men­tal health and psychiatry, proposes, if passed, to:
   • enhance evidence-based and sci­entifically validated interventions in the public sector
   • raise the profile of mental health within the federal government by creat­ing a position of Assistant Secretary for Mental Health in the U.S. Department of Health and Human Services, who will have oversight of both research and mental health care within the fed­eral government.

Unacceptable disparity must be remedied
Planning an effective therapeutic pla­centa is imperative if health care for SMI patients is to approach the comprehen­sive spectrum of treatment, rehabilita­tion, and prevention available to stroke patients. Although stroke is regarded as a sensory-motor brain disorder, it is also associated with mental symp­toms, just as schizophrenia is associ­ated with sensory-motor symptoms. Both are disabling brain disorders: one, physically and cognitively; the other, mentally and socially. Both require a therapeutic placenta: Stroke is sup­ported by one; schizophrenia is not. This is an unacceptable disparity that must be addressed—soon.

Perhaps more than any other medical specialty, psychiatry enjoys a longstanding and, at times, complicated relationship with cinema. Recent award-winning films, such as Still Alice, Silver Linings Playbook, and Birdman: Or (The Unexpected Virtue of Ignorance) continue traditions rooted in One Flew Over the Cuckoo’s Nest, Martha Marcy May Marlene, Spellbound, and dozens of other films. Through these films, psychiatry is afforded exposure unavailable to most medical specialties. This exposure has proven to be a double-edged sword, however.

Exposure vs accurate portrayal
Relative benefits and disadvantages of psychiatry’s position in film and popular media are difficult to calculate. A film such as Still Alice can provide a vivid, concrete personal narrative of a patient with Alzheimer’s disease, equipping millions of viewers with knowledge that might otherwise remain esoteric and inaccessible. Martha Marcy May Marlene offers a similar stage for posttraumatic stress disorder (PTSD), as does Spellbound for dissociative amnesia.

Such exposure comes at a cost, inevitably, because information about psychiatry is incorporated into a dramatic storyline assembled by filmmakers who are not medical professionals and who are bound by conflicting pressures. At times, those pressures outweigh the desire to accurately portray psychiatric illness.

‘Magical realism’
Two of last year’s celebrated films, Birdman and Still Alice, have continued the longstanding tradition of portraying mental illness in film. Medicine often is touted as art and science; film likewise sits at this intersection. However, filmmakers are artists, primarily, and the nature of storytelling is to emphasize art over scientific accuracy.

The main character in Birdman, for example, manifests psychosis, but many of his presenting signs and symptoms are incongruent with any diagnosable form of psychosis. To tell its story, the film employs magical realism, a celebrated literary and film technique. Although magical realism might detract from the accuracy of the condition portrayed, it adds cinematic appeal to the film, likely creates more entertainment value, and, in turn, garners appreciation from a broader audience.

Expansion of medical information, accurate and otherwise
As in the 1970’s, we are, today, in the midst of rapidly evolving societal norms. One of the most rapid changes is in how the public acquires information. We are in the midst of the “Googlification” of medical knowledge and the expansion of online medical resources. These resources can, simultaneously, inform and mislead the public.

Popular films behave in much the same way. There is no motion picture-guild requirement that mentally ill characters in films such as Birdman meet any set of psychiatric criteria, from DSM-5 or elsewhere. Similarly, the fact that psychiatrists do not control the information in films that portray mental illness comes as no surprise.

‘One flew East, one flew West…’
The tension between engaging storytelling and medical accuracy certainly is not a new phenomenon, extending not only to representations of disease but to representations of treatment. Consider director Miloš Forman’s seminal 1975 film, One Flew Over the Cuckoo’s Nest, whose chief importance for psychiatry rests not in its individualized representations of patients but in a portrayal of the environment in which they are treated. Louise Fletcher’s Academy Award-winning portrayal of cruel Nurse Ratched has lingered in the public consciousness, remaining a prominent image for many Americans when they think of a psychiatric institution.

When Cuckoo’s Nest was released, it was considered by critics to be an “exploration of society’s enforcement of conformism” that “almost willfully overlooked the realities of mental illness”¹ so that it could vivify its protagonist’s struggle against tyrannical Nurse Ratched. The film’s primary intent might not have been to make a statement about the injustices of the time, but it has certainly had a lasting effect on the public’s perception of psychiatric illness and treatment.

Films offer an opportunity for discussion
Films on the theme of psychiatry and mental illness have long held a distinctive position in the canon of Western cinema. In this vein, films from the past year have made timely contributions to the genre. Although Still Alice and Birdman might prove to be ground-breaking in changing societal views over time, we must not expect them to do so.

Nevertheless, psychiatry ought to take advantage of popular films’ wide exposure and ability to destigmatize mental illness—rather than lament medical inaccuracies in these films.

Cinema is, first and foremost, an art. Although patients and the public might pick up misconceptions about psychosis, Alzheimer’s disease, or PTSD because popular films take artistic liberty about mental illness, psychiatrists are available to set the record straight. After all, psychiatry has long been about managing perceptions, and patient education is at the core of our specialty.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Perhaps more than any other medical specialty, psychiatry enjoys a longstanding and, at times, complicated relationship with cinema. Recent award-winning films, such as Still Alice, Silver Linings Playbook, and Birdman: Or (The Unexpected Virtue of Ignorance) continue traditions rooted in One Flew Over the Cuckoo’s Nest, Martha Marcy May Marlene, Spellbound, and dozens of other films. Through these films, psychiatry is afforded exposure unavailable to most medical specialties. This exposure has proven to be a double-edged sword, however.

Exposure vs accurate portrayal
Relative benefits and disadvantages of psychiatry’s position in film and popular media are difficult to calculate. A film such as Still Alice can provide a vivid, concrete personal narrative of a patient with Alzheimer’s disease, equipping millions of viewers with knowledge that might otherwise remain esoteric and inaccessible. Martha Marcy May Marlene offers a similar stage for posttraumatic stress disorder (PTSD), as does Spellbound for dissociative amnesia.

Such exposure comes at a cost, inevitably, because information about psychiatry is incorporated into a dramatic storyline assembled by filmmakers who are not medical professionals and who are bound by conflicting pressures. At times, those pressures outweigh the desire to accurately portray psychiatric illness.

‘Magical realism’
Two of last year’s celebrated films, Birdman and Still Alice, have continued the longstanding tradition of portraying mental illness in film. Medicine often is touted as art and science; film likewise sits at this intersection. However, filmmakers are artists, primarily, and the nature of storytelling is to emphasize art over scientific accuracy.

The main character in Birdman, for example, manifests psychosis, but many of his presenting signs and symptoms are incongruent with any diagnosable form of psychosis. To tell its story, the film employs magical realism, a celebrated literary and film technique. Although magical realism might detract from the accuracy of the condition portrayed, it adds cinematic appeal to the film, likely creates more entertainment value, and, in turn, garners appreciation from a broader audience.

Expansion of medical information, accurate and otherwise
As in the 1970’s, we are, today, in the midst of rapidly evolving societal norms. One of the most rapid changes is in how the public acquires information. We are in the midst of the “Googlification” of medical knowledge and the expansion of online medical resources. These resources can, simultaneously, inform and mislead the public.

Popular films behave in much the same way. There is no motion picture-guild requirement that mentally ill characters in films such as Birdman meet any set of psychiatric criteria, from DSM-5 or elsewhere. Similarly, the fact that psychiatrists do not control the information in films that portray mental illness comes as no surprise.

‘One flew East, one flew West…’
The tension between engaging storytelling and medical accuracy certainly is not a new phenomenon, extending not only to representations of disease but to representations of treatment. Consider director Miloš Forman’s seminal 1975 film, One Flew Over the Cuckoo’s Nest, whose chief importance for psychiatry rests not in its individualized representations of patients but in a portrayal of the environment in which they are treated. Louise Fletcher’s Academy Award-winning portrayal of cruel Nurse Ratched has lingered in the public consciousness, remaining a prominent image for many Americans when they think of a psychiatric institution.

When Cuckoo’s Nest was released, it was considered by critics to be an “exploration of society’s enforcement of conformism” that “almost willfully overlooked the realities of mental illness”¹ so that it could vivify its protagonist’s struggle against tyrannical Nurse Ratched. The film’s primary intent might not have been to make a statement about the injustices of the time, but it has certainly had a lasting effect on the public’s perception of psychiatric illness and treatment.

Films offer an opportunity for discussion
Films on the theme of psychiatry and mental illness have long held a distinctive position in the canon of Western cinema. In this vein, films from the past year have made timely contributions to the genre. Although Still Alice and Birdman might prove to be ground-breaking in changing societal views over time, we must not expect them to do so.

Nevertheless, psychiatry ought to take advantage of popular films’ wide exposure and ability to destigmatize mental illness—rather than lament medical inaccuracies in these films.

Cinema is, first and foremost, an art. Although patients and the public might pick up misconceptions about psychosis, Alzheimer’s disease, or PTSD because popular films take artistic liberty about mental illness, psychiatrists are available to set the record straight. After all, psychiatry has long been about managing perceptions, and patient education is at the core of our specialty.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Perhaps more than any other medical specialty, psychiatry enjoys a longstanding and, at times, complicated relationship with cinema. Recent award-winning films, such as Still Alice, Silver Linings Playbook, and Birdman: Or (The Unexpected Virtue of Ignorance) continue traditions rooted in One Flew Over the Cuckoo’s Nest, Martha Marcy May Marlene, Spellbound, and dozens of other films. Through these films, psychiatry is afforded exposure unavailable to most medical specialties. This exposure has proven to be a double-edged sword, however.

Exposure vs accurate portrayal
Relative benefits and disadvantages of psychiatry’s position in film and popular media are difficult to calculate. A film such as Still Alice can provide a vivid, concrete personal narrative of a patient with Alzheimer’s disease, equipping millions of viewers with knowledge that might otherwise remain esoteric and inaccessible. Martha Marcy May Marlene offers a similar stage for posttraumatic stress disorder (PTSD), as does Spellbound for dissociative amnesia.

Such exposure comes at a cost, inevitably, because information about psychiatry is incorporated into a dramatic storyline assembled by filmmakers who are not medical professionals and who are bound by conflicting pressures. At times, those pressures outweigh the desire to accurately portray psychiatric illness.

‘Magical realism’
Two of last year’s celebrated films, Birdman and Still Alice, have continued the longstanding tradition of portraying mental illness in film. Medicine often is touted as art and science; film likewise sits at this intersection. However, filmmakers are artists, primarily, and the nature of storytelling is to emphasize art over scientific accuracy.

The main character in Birdman, for example, manifests psychosis, but many of his presenting signs and symptoms are incongruent with any diagnosable form of psychosis. To tell its story, the film employs magical realism, a celebrated literary and film technique. Although magical realism might detract from the accuracy of the condition portrayed, it adds cinematic appeal to the film, likely creates more entertainment value, and, in turn, garners appreciation from a broader audience.

Expansion of medical information, accurate and otherwise
As in the 1970’s, we are, today, in the midst of rapidly evolving societal norms. One of the most rapid changes is in how the public acquires information. We are in the midst of the “Googlification” of medical knowledge and the expansion of online medical resources. These resources can, simultaneously, inform and mislead the public.

Popular films behave in much the same way. There is no motion picture-guild requirement that mentally ill characters in films such as Birdman meet any set of psychiatric criteria, from DSM-5 or elsewhere. Similarly, the fact that psychiatrists do not control the information in films that portray mental illness comes as no surprise.

‘One flew East, one flew West…’
The tension between engaging storytelling and medical accuracy certainly is not a new phenomenon, extending not only to representations of disease but to representations of treatment. Consider director Miloš Forman’s seminal 1975 film, One Flew Over the Cuckoo’s Nest, whose chief importance for psychiatry rests not in its individualized representations of patients but in a portrayal of the environment in which they are treated. Louise Fletcher’s Academy Award-winning portrayal of cruel Nurse Ratched has lingered in the public consciousness, remaining a prominent image for many Americans when they think of a psychiatric institution.

When Cuckoo’s Nest was released, it was considered by critics to be an “exploration of society’s enforcement of conformism” that “almost willfully overlooked the realities of mental illness”¹ so that it could vivify its protagonist’s struggle against tyrannical Nurse Ratched. The film’s primary intent might not have been to make a statement about the injustices of the time, but it has certainly had a lasting effect on the public’s perception of psychiatric illness and treatment.

Films offer an opportunity for discussion
Films on the theme of psychiatry and mental illness have long held a distinctive position in the canon of Western cinema. In this vein, films from the past year have made timely contributions to the genre. Although Still Alice and Birdman might prove to be ground-breaking in changing societal views over time, we must not expect them to do so.

Nevertheless, psychiatry ought to take advantage of popular films’ wide exposure and ability to destigmatize mental illness—rather than lament medical inaccuracies in these films.

Cinema is, first and foremost, an art. Although patients and the public might pick up misconceptions about psychosis, Alzheimer’s disease, or PTSD because popular films take artistic liberty about mental illness, psychiatrists are available to set the record straight. After all, psychiatry has long been about managing perceptions, and patient education is at the core of our specialty.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The mnemonic CUT DOWNTIME, which I have adapted and modi­fied from the book Lean Healthcare Deployment and Sustainability,¹ breaks down waste in health care—an activity that adds no value to a service—into 11 major categories (Table). This mnemonic provides the busy practitioner a simple framework for improving quality and efficiency of services by identifying and eliminating wastes the Lean way.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The mnemonic CUT DOWNTIME, which I have adapted and modi­fied from the book Lean Healthcare Deployment and Sustainability,¹ breaks down waste in health care—an activity that adds no value to a service—into 11 major categories (Table). This mnemonic provides the busy practitioner a simple framework for improving quality and efficiency of services by identifying and eliminating wastes the Lean way.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The mnemonic CUT DOWNTIME, which I have adapted and modi­fied from the book Lean Healthcare Deployment and Sustainability,¹ breaks down waste in health care—an activity that adds no value to a service—into 11 major categories (Table). This mnemonic provides the busy practitioner a simple framework for improving quality and efficiency of services by identifying and eliminating wastes the Lean way.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The Social Security Administration (SSA) does not provide much guid­ance on the contentious issue of determining payeeship for disability ben­eficiaries. The only description available is stated on the “Physician/medical officer’s statement of patient’s capability to man­age benefits” (form SSA-787): “By capable we mean that the patient: Is able to under­stand and act on the ordinary affairs of life, such as providing for own adequate food, housing, etc., and is able, in spite of physi­cal impairments, to manage funds or direct others how to manage them.”

Physicians will be asked to make a capa­bility statement if they are performing a consultative examination for SSA or if their patient:
   • is applying for benefits
   • needs to have a payee.

Regrettably, the published literature on capability is scant.^1,2 Based on decades of personal experience, here is the approach I have adopted to determine capability.

Diagnoses, circumstances, and clini­cal syndromes that strongly suggest the need for a payee include those listed in the Table.

The psychiatric rehabilitation agency I work at adheres to a recovery model. I consult with caseworkers on the issue of capability, but generally endorse a “team” recommendation for initiating or termi­nating payeeship. A number of factors are involved:

Adherence to recovery means that we encourage autonomy; we do not attempt to prevent every bad decision.

Demands for money from the patient and demands to terminate payeeship can be strident and potentially violent.

Confrontations over payeeship can be a safety risk for family or staff who have been acting as the payee. 

Guardianship (or conservatorship) is a judicially determined restriction of financial decision-making.

Payeeship is an extrajudicial restriction of financial decision-making. Treating physicians, understandably, may feel uneasy restricting the rights of a patient. Additionally, there is ethical stress when a physician does anything that might compromise the primacy of the treatment relationship.

If all parties agree that payeeship should be terminated, I recommend the payee (whether the family or an institutional payee) begin a 3-month trial, during which the payee does not pay bills or keep a bud­get. The patient receives his (her) money in a lump sum at the beginning of the month, which begins a naturalistic trial of the patient’s capability to pay rent and budget adequately for all other necessities. If the patient demonstrates capability, I sign the SSA-787 form.

Offering a structured plan for restor­ing a patient’s benefits could defuse hostile demands.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The Social Security Administration (SSA) does not provide much guid­ance on the contentious issue of determining payeeship for disability ben­eficiaries. The only description available is stated on the “Physician/medical officer’s statement of patient’s capability to man­age benefits” (form SSA-787): “By capable we mean that the patient: Is able to under­stand and act on the ordinary affairs of life, such as providing for own adequate food, housing, etc., and is able, in spite of physi­cal impairments, to manage funds or direct others how to manage them.”

Physicians will be asked to make a capa­bility statement if they are performing a consultative examination for SSA or if their patient:
   • is applying for benefits
   • needs to have a payee.

Regrettably, the published literature on capability is scant.^1,2 Based on decades of personal experience, here is the approach I have adopted to determine capability.

Diagnoses, circumstances, and clini­cal syndromes that strongly suggest the need for a payee include those listed in the Table.

The psychiatric rehabilitation agency I work at adheres to a recovery model. I consult with caseworkers on the issue of capability, but generally endorse a “team” recommendation for initiating or termi­nating payeeship. A number of factors are involved:

Adherence to recovery means that we encourage autonomy; we do not attempt to prevent every bad decision.

Demands for money from the patient and demands to terminate payeeship can be strident and potentially violent.

Confrontations over payeeship can be a safety risk for family or staff who have been acting as the payee. 

Guardianship (or conservatorship) is a judicially determined restriction of financial decision-making.

Payeeship is an extrajudicial restriction of financial decision-making. Treating physicians, understandably, may feel uneasy restricting the rights of a patient. Additionally, there is ethical stress when a physician does anything that might compromise the primacy of the treatment relationship.

If all parties agree that payeeship should be terminated, I recommend the payee (whether the family or an institutional payee) begin a 3-month trial, during which the payee does not pay bills or keep a bud­get. The patient receives his (her) money in a lump sum at the beginning of the month, which begins a naturalistic trial of the patient’s capability to pay rent and budget adequately for all other necessities. If the patient demonstrates capability, I sign the SSA-787 form.

Offering a structured plan for restor­ing a patient’s benefits could defuse hostile demands.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

The Social Security Administration (SSA) does not provide much guid­ance on the contentious issue of determining payeeship for disability ben­eficiaries. The only description available is stated on the “Physician/medical officer’s statement of patient’s capability to man­age benefits” (form SSA-787): “By capable we mean that the patient: Is able to under­stand and act on the ordinary affairs of life, such as providing for own adequate food, housing, etc., and is able, in spite of physi­cal impairments, to manage funds or direct others how to manage them.”

Physicians will be asked to make a capa­bility statement if they are performing a consultative examination for SSA or if their patient:
   • is applying for benefits
   • needs to have a payee.

Regrettably, the published literature on capability is scant.^1,2 Based on decades of personal experience, here is the approach I have adopted to determine capability.

Diagnoses, circumstances, and clini­cal syndromes that strongly suggest the need for a payee include those listed in the Table.

The psychiatric rehabilitation agency I work at adheres to a recovery model. I consult with caseworkers on the issue of capability, but generally endorse a “team” recommendation for initiating or termi­nating payeeship. A number of factors are involved:

Adherence to recovery means that we encourage autonomy; we do not attempt to prevent every bad decision.

Demands for money from the patient and demands to terminate payeeship can be strident and potentially violent.

Confrontations over payeeship can be a safety risk for family or staff who have been acting as the payee. 

Guardianship (or conservatorship) is a judicially determined restriction of financial decision-making.

Payeeship is an extrajudicial restriction of financial decision-making. Treating physicians, understandably, may feel uneasy restricting the rights of a patient. Additionally, there is ethical stress when a physician does anything that might compromise the primacy of the treatment relationship.

If all parties agree that payeeship should be terminated, I recommend the payee (whether the family or an institutional payee) begin a 3-month trial, during which the payee does not pay bills or keep a bud­get. The patient receives his (her) money in a lump sum at the beginning of the month, which begins a naturalistic trial of the patient’s capability to pay rent and budget adequately for all other necessities. If the patient demonstrates capability, I sign the SSA-787 form.

Offering a structured plan for restor­ing a patient’s benefits could defuse hostile demands.

Disclosure
The author reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman,

I practice in a state that allows medical mari­juana use. A few of my patients have asked me to help them obtain marijuana for their conditions. How risky would it be to oblige?

Submitted by “Dr. J”

In recent years, public debate about mar­ijuana has acquired 2 new dimensions: (1) the wishes and medical needs of peo­ple who seek marijuana for its purported health benefits, and (2) the role of physi­cians who practice where “medical mari­juana” is legal. This article, the authors’ joint effort to address Dr. J’s concerns, hits 3 topics:
   • the intersection of marijuana policy and health care in the United States
   • the risks and possible benefits of mari­juana use
   • the medicolegal problems faced by physicians who might advise patients to use marijuana.

Legal haze
Two cannabinoids—dronabinol and nabi­lone—have received FDA approval as appetite enhancers and anti-nausea agents. Third-party payors usually cover these types of medications, but no insurer pays for medical marijuana.¹ The Controlled Substances Act of 1970² classified mari­juana as a Schedule I drug because of its abuse potential, lack of accepted medical applications, and uncertain safety. The FDA has not approved marijuana use for any medical condition.

Although people commonly speak of “prescribing” marijuana, physicians cannot legally do this in the United States. What physicians may do, in the 23 states that allow medical marijuana, is recommend or certify a patient’s marijuana use—an action that has constitutional protection under the First Amendment’s freedom of speech clause.^3,4

A physician may complete documenta­tion that a patient has one of the qualifying medical conditions for which the jurisdic­tion has legalized medical marijuana. Either the patient or the physician then submits that documentation to the appropriate gov­ernment agency (eg, the state’s department of health).

If the documentation receives approval, the agency will issue the patient a registra­tion card that allows possession of medi­cal marijuana, with which the patient can obtain or grow a small amount of mari­juana. The cannabinoid content of mari­juana products varies considerably,⁵ and physicians who certify marijuana typi­cally defer dosage recommendations to the patient or the dispensary.¹

In states that allow medical marijuana, users may assert an affirmative defense of medical necessity if they face criminal pros­ecution.^3,6 Possession of marijuana remains illegal under federal law, however, regard­less of one’s reason for having it.^7,8 Since October 2009, the Attorney General’s office has discouraged federal prosecutions of per­sons “whose actions are in clear and unam­biguous compliance with existing state laws providing for the medical use of mari­juana.”⁹ But given the remaining conflicts between state and federal laws, “the legal implications of certifying patients for medi­cal marijuana remain unclear.”¹⁰

Physicians have few resources to instruct them on the legal risks of certifying medical marijuana. When Canada legalized medical marijuana, the organization that provides malpractice insurance to Canadian physi­cians told its members that “prescribing medical marijuana cannot be compared to prescribing prescription drugs” and rec­ommended that physicians obtain signed release forms documenting that they have discussed the risks of medical marijuana with patients.¹¹ For some risky approved drugs, the FDA has established a risk evalu­ation and mitigation strategy, but no such guidance is available for marijuana.

Highlighting the benefits and risks
Proponents of medical marijuana claim that Cannabis can help patients, and dispas­sionate experts acknowledge that at least modest evidence supports the benefits of using “marijuana for nausea and vomit­ing related to chemotherapy, specific pain syndromes, and spasticity from multiple sclerosis.”¹⁰ For several other conditions— HIV/AIDS, depression, anxiety disor­ders, sleep disorders, psychosis, Tourette syndrome—evidence of benefit is poor.¹² Rigorous evaluation of medical marijuana is difficult because the plant contains hun­dreds of active chemical compounds. The chemical content of marijuana is highly variable, depending on its preparation and administration,^10,13—one reason why only a few good randomized controlled trials of marijuana have been conducted.

Marijuana has several side effects and carries many health risks (Table 1).^4,14-20

On the highway: Marijuana and driving
Marijuana use impairs driving ability.¹⁴ Following enactment of more lenient mari­juana laws, several states have reported higher numbers of fatally injured drivers who tested positive for Cannabis^21-23 and had a positive screen of tetrahydrocannabi­nol (THC) in driving under the influence cases.^24,25 One study showed that a blood THC concentration >5 ng/mL (comparable to a blood alcohol concentration of 0.15%) increased the crash odds ratio to 6.^6.25,26

Marijuana impairs reaction time, informa­tion processing, motor performance, atten­tion, and visual processing.^14,16,27,28 Drivers who are under the influence of marijuana make more driving errors, despite being cautious about how they react to traffic.²⁹ Even after weeks of abstinence, previ­ous daily users of marijuana display some cognitive processing and driving-related impairments.^30,31

Courts have found physicians negligent if their patients’ treatment-induced driving impairments injured others when the risk of driving-related injury was foreseeable.³² The Massachusetts case of Coombes v Florio³³ lik­ened the physician’s duty to that of a liquor store that sells alcohol to a minor who sub­sequently crashes, or to a father who did not lock his firearms away from his violent adult son.

Three variables influence a court’s judgment about whether risk is “foresee­able”: “the relative knowledge of the risk as between lay persons and physicians, whether the patient has previously used the medication and/or experienced the adverse effect, and whether a warning would other­wise have been futile.”³⁴ A physician who certified a patient to use marijuana without adequately explaining the risks of driv­ing might be vulnerable to a lawsuit if the patient’s driving accident occurred while the patient was under the influence of the drug. Recommending marijuana as a treat­ment also could lead to a malpractice action if a patient experienced and was harmed by the drug’s adverse effects.

Other drags
Another malpractice risk stems from mari­juana’s addiction potential. Although many people think Cannabis isn’t addictive, nearly 10% of all marijuana users develop depen­dence.^10,17 Regular Cannabis users are more likely to use alcohol, tobacco, and “recre­ational” drugs,^17,35 and using alcohol and marijuana together greatly heightens the risk of driving accidents.^14,15 Although we know of no case that relates directly to mari­juana, physicians have faced lawsuits for injuries stemming from a patient’s addiction to prescription drugs,36 particularly when the patient’s behavior should have led the physician to suspect abuse or overuse.³⁷

When certifying marijuana use, physi­cians have the same obligations that apply to more conventional medical treatment:
   • establishing a proper physician–patient relationship
   • taking an appropriate history
   • conducting a proper examination
   • reviewing records
   • developing a comprehensive treatment plan
   • weighing risks and alternatives
   • providing follow-up care.

Neglecting these steps could lead to medical board sanctions and suspension or revocation of a medical license.¹³

The blunt reality
We advise against recommending mari­juana for your patients. But if you have exhausted the alternatives, see marijuana as the last resort, and believe that taking the risk is worth the potential benefit, you can take some steps to reduce your legal risk (Table 2,^1,32,37,38 and Table 3¹³).

Bottom LinE
Medical marijuana is a controversial topic that demands more rigorous research and regulatory consideration. In the present climate, cautious physicians will avoid recommending marijuana to their patients. If you think that a patient has a medical indication, with no treatment option better than medical marijuana, be sure to understand the medical and legal ramifications before you authorize its use.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman,

I practice in a state that allows medical mari­juana use. A few of my patients have asked me to help them obtain marijuana for their conditions. How risky would it be to oblige?

Submitted by “Dr. J”

In recent years, public debate about mar­ijuana has acquired 2 new dimensions: (1) the wishes and medical needs of peo­ple who seek marijuana for its purported health benefits, and (2) the role of physi­cians who practice where “medical mari­juana” is legal. This article, the authors’ joint effort to address Dr. J’s concerns, hits 3 topics:
   • the intersection of marijuana policy and health care in the United States
   • the risks and possible benefits of mari­juana use
   • the medicolegal problems faced by physicians who might advise patients to use marijuana.

Legal haze
Two cannabinoids—dronabinol and nabi­lone—have received FDA approval as appetite enhancers and anti-nausea agents. Third-party payors usually cover these types of medications, but no insurer pays for medical marijuana.¹ The Controlled Substances Act of 1970² classified mari­juana as a Schedule I drug because of its abuse potential, lack of accepted medical applications, and uncertain safety. The FDA has not approved marijuana use for any medical condition.

Although people commonly speak of “prescribing” marijuana, physicians cannot legally do this in the United States. What physicians may do, in the 23 states that allow medical marijuana, is recommend or certify a patient’s marijuana use—an action that has constitutional protection under the First Amendment’s freedom of speech clause.^3,4

A physician may complete documenta­tion that a patient has one of the qualifying medical conditions for which the jurisdic­tion has legalized medical marijuana. Either the patient or the physician then submits that documentation to the appropriate gov­ernment agency (eg, the state’s department of health).

If the documentation receives approval, the agency will issue the patient a registra­tion card that allows possession of medi­cal marijuana, with which the patient can obtain or grow a small amount of mari­juana. The cannabinoid content of mari­juana products varies considerably,⁵ and physicians who certify marijuana typi­cally defer dosage recommendations to the patient or the dispensary.¹

In states that allow medical marijuana, users may assert an affirmative defense of medical necessity if they face criminal pros­ecution.^3,6 Possession of marijuana remains illegal under federal law, however, regard­less of one’s reason for having it.^7,8 Since October 2009, the Attorney General’s office has discouraged federal prosecutions of per­sons “whose actions are in clear and unam­biguous compliance with existing state laws providing for the medical use of mari­juana.”⁹ But given the remaining conflicts between state and federal laws, “the legal implications of certifying patients for medi­cal marijuana remain unclear.”¹⁰

Physicians have few resources to instruct them on the legal risks of certifying medical marijuana. When Canada legalized medical marijuana, the organization that provides malpractice insurance to Canadian physi­cians told its members that “prescribing medical marijuana cannot be compared to prescribing prescription drugs” and rec­ommended that physicians obtain signed release forms documenting that they have discussed the risks of medical marijuana with patients.¹¹ For some risky approved drugs, the FDA has established a risk evalu­ation and mitigation strategy, but no such guidance is available for marijuana.

Highlighting the benefits and risks
Proponents of medical marijuana claim that Cannabis can help patients, and dispas­sionate experts acknowledge that at least modest evidence supports the benefits of using “marijuana for nausea and vomit­ing related to chemotherapy, specific pain syndromes, and spasticity from multiple sclerosis.”¹⁰ For several other conditions— HIV/AIDS, depression, anxiety disor­ders, sleep disorders, psychosis, Tourette syndrome—evidence of benefit is poor.¹² Rigorous evaluation of medical marijuana is difficult because the plant contains hun­dreds of active chemical compounds. The chemical content of marijuana is highly variable, depending on its preparation and administration,^10,13—one reason why only a few good randomized controlled trials of marijuana have been conducted.

Marijuana has several side effects and carries many health risks (Table 1).^4,14-20

On the highway: Marijuana and driving
Marijuana use impairs driving ability.¹⁴ Following enactment of more lenient mari­juana laws, several states have reported higher numbers of fatally injured drivers who tested positive for Cannabis^21-23 and had a positive screen of tetrahydrocannabi­nol (THC) in driving under the influence cases.^24,25 One study showed that a blood THC concentration >5 ng/mL (comparable to a blood alcohol concentration of 0.15%) increased the crash odds ratio to 6.^6.25,26

Marijuana impairs reaction time, informa­tion processing, motor performance, atten­tion, and visual processing.^14,16,27,28 Drivers who are under the influence of marijuana make more driving errors, despite being cautious about how they react to traffic.²⁹ Even after weeks of abstinence, previ­ous daily users of marijuana display some cognitive processing and driving-related impairments.^30,31

Courts have found physicians negligent if their patients’ treatment-induced driving impairments injured others when the risk of driving-related injury was foreseeable.³² The Massachusetts case of Coombes v Florio³³ lik­ened the physician’s duty to that of a liquor store that sells alcohol to a minor who sub­sequently crashes, or to a father who did not lock his firearms away from his violent adult son.

Three variables influence a court’s judgment about whether risk is “foresee­able”: “the relative knowledge of the risk as between lay persons and physicians, whether the patient has previously used the medication and/or experienced the adverse effect, and whether a warning would other­wise have been futile.”³⁴ A physician who certified a patient to use marijuana without adequately explaining the risks of driv­ing might be vulnerable to a lawsuit if the patient’s driving accident occurred while the patient was under the influence of the drug. Recommending marijuana as a treat­ment also could lead to a malpractice action if a patient experienced and was harmed by the drug’s adverse effects.

Other drags
Another malpractice risk stems from mari­juana’s addiction potential. Although many people think Cannabis isn’t addictive, nearly 10% of all marijuana users develop depen­dence.^10,17 Regular Cannabis users are more likely to use alcohol, tobacco, and “recre­ational” drugs,^17,35 and using alcohol and marijuana together greatly heightens the risk of driving accidents.^14,15 Although we know of no case that relates directly to mari­juana, physicians have faced lawsuits for injuries stemming from a patient’s addiction to prescription drugs,36 particularly when the patient’s behavior should have led the physician to suspect abuse or overuse.³⁷

When certifying marijuana use, physi­cians have the same obligations that apply to more conventional medical treatment:
   • establishing a proper physician–patient relationship
   • taking an appropriate history
   • conducting a proper examination
   • reviewing records
   • developing a comprehensive treatment plan
   • weighing risks and alternatives
   • providing follow-up care.

Neglecting these steps could lead to medical board sanctions and suspension or revocation of a medical license.¹³

The blunt reality
We advise against recommending mari­juana for your patients. But if you have exhausted the alternatives, see marijuana as the last resort, and believe that taking the risk is worth the potential benefit, you can take some steps to reduce your legal risk (Table 2,^1,32,37,38 and Table 3¹³).

Bottom LinE
Medical marijuana is a controversial topic that demands more rigorous research and regulatory consideration. In the present climate, cautious physicians will avoid recommending marijuana to their patients. If you think that a patient has a medical indication, with no treatment option better than medical marijuana, be sure to understand the medical and legal ramifications before you authorize its use.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dear Dr. Mossman,

I practice in a state that allows medical mari­juana use. A few of my patients have asked me to help them obtain marijuana for their conditions. How risky would it be to oblige?

Submitted by “Dr. J”

In recent years, public debate about mar­ijuana has acquired 2 new dimensions: (1) the wishes and medical needs of peo­ple who seek marijuana for its purported health benefits, and (2) the role of physi­cians who practice where “medical mari­juana” is legal. This article, the authors’ joint effort to address Dr. J’s concerns, hits 3 topics:
   • the intersection of marijuana policy and health care in the United States
   • the risks and possible benefits of mari­juana use
   • the medicolegal problems faced by physicians who might advise patients to use marijuana.

Legal haze
Two cannabinoids—dronabinol and nabi­lone—have received FDA approval as appetite enhancers and anti-nausea agents. Third-party payors usually cover these types of medications, but no insurer pays for medical marijuana.¹ The Controlled Substances Act of 1970² classified mari­juana as a Schedule I drug because of its abuse potential, lack of accepted medical applications, and uncertain safety. The FDA has not approved marijuana use for any medical condition.

Although people commonly speak of “prescribing” marijuana, physicians cannot legally do this in the United States. What physicians may do, in the 23 states that allow medical marijuana, is recommend or certify a patient’s marijuana use—an action that has constitutional protection under the First Amendment’s freedom of speech clause.^3,4

A physician may complete documenta­tion that a patient has one of the qualifying medical conditions for which the jurisdic­tion has legalized medical marijuana. Either the patient or the physician then submits that documentation to the appropriate gov­ernment agency (eg, the state’s department of health).

If the documentation receives approval, the agency will issue the patient a registra­tion card that allows possession of medi­cal marijuana, with which the patient can obtain or grow a small amount of mari­juana. The cannabinoid content of mari­juana products varies considerably,⁵ and physicians who certify marijuana typi­cally defer dosage recommendations to the patient or the dispensary.¹

In states that allow medical marijuana, users may assert an affirmative defense of medical necessity if they face criminal pros­ecution.^3,6 Possession of marijuana remains illegal under federal law, however, regard­less of one’s reason for having it.^7,8 Since October 2009, the Attorney General’s office has discouraged federal prosecutions of per­sons “whose actions are in clear and unam­biguous compliance with existing state laws providing for the medical use of mari­juana.”⁹ But given the remaining conflicts between state and federal laws, “the legal implications of certifying patients for medi­cal marijuana remain unclear.”¹⁰

Physicians have few resources to instruct them on the legal risks of certifying medical marijuana. When Canada legalized medical marijuana, the organization that provides malpractice insurance to Canadian physi­cians told its members that “prescribing medical marijuana cannot be compared to prescribing prescription drugs” and rec­ommended that physicians obtain signed release forms documenting that they have discussed the risks of medical marijuana with patients.¹¹ For some risky approved drugs, the FDA has established a risk evalu­ation and mitigation strategy, but no such guidance is available for marijuana.

Highlighting the benefits and risks
Proponents of medical marijuana claim that Cannabis can help patients, and dispas­sionate experts acknowledge that at least modest evidence supports the benefits of using “marijuana for nausea and vomit­ing related to chemotherapy, specific pain syndromes, and spasticity from multiple sclerosis.”¹⁰ For several other conditions— HIV/AIDS, depression, anxiety disor­ders, sleep disorders, psychosis, Tourette syndrome—evidence of benefit is poor.¹² Rigorous evaluation of medical marijuana is difficult because the plant contains hun­dreds of active chemical compounds. The chemical content of marijuana is highly variable, depending on its preparation and administration,^10,13—one reason why only a few good randomized controlled trials of marijuana have been conducted.

Marijuana has several side effects and carries many health risks (Table 1).^4,14-20

On the highway: Marijuana and driving
Marijuana use impairs driving ability.¹⁴ Following enactment of more lenient mari­juana laws, several states have reported higher numbers of fatally injured drivers who tested positive for Cannabis^21-23 and had a positive screen of tetrahydrocannabi­nol (THC) in driving under the influence cases.^24,25 One study showed that a blood THC concentration >5 ng/mL (comparable to a blood alcohol concentration of 0.15%) increased the crash odds ratio to 6.^6.25,26

Marijuana impairs reaction time, informa­tion processing, motor performance, atten­tion, and visual processing.^14,16,27,28 Drivers who are under the influence of marijuana make more driving errors, despite being cautious about how they react to traffic.²⁹ Even after weeks of abstinence, previ­ous daily users of marijuana display some cognitive processing and driving-related impairments.^30,31

Courts have found physicians negligent if their patients’ treatment-induced driving impairments injured others when the risk of driving-related injury was foreseeable.³² The Massachusetts case of Coombes v Florio³³ lik­ened the physician’s duty to that of a liquor store that sells alcohol to a minor who sub­sequently crashes, or to a father who did not lock his firearms away from his violent adult son.

Three variables influence a court’s judgment about whether risk is “foresee­able”: “the relative knowledge of the risk as between lay persons and physicians, whether the patient has previously used the medication and/or experienced the adverse effect, and whether a warning would other­wise have been futile.”³⁴ A physician who certified a patient to use marijuana without adequately explaining the risks of driv­ing might be vulnerable to a lawsuit if the patient’s driving accident occurred while the patient was under the influence of the drug. Recommending marijuana as a treat­ment also could lead to a malpractice action if a patient experienced and was harmed by the drug’s adverse effects.

Other drags
Another malpractice risk stems from mari­juana’s addiction potential. Although many people think Cannabis isn’t addictive, nearly 10% of all marijuana users develop depen­dence.^10,17 Regular Cannabis users are more likely to use alcohol, tobacco, and “recre­ational” drugs,^17,35 and using alcohol and marijuana together greatly heightens the risk of driving accidents.^14,15 Although we know of no case that relates directly to mari­juana, physicians have faced lawsuits for injuries stemming from a patient’s addiction to prescription drugs,36 particularly when the patient’s behavior should have led the physician to suspect abuse or overuse.³⁷

When certifying marijuana use, physi­cians have the same obligations that apply to more conventional medical treatment:
   • establishing a proper physician–patient relationship
   • taking an appropriate history
   • conducting a proper examination
   • reviewing records
   • developing a comprehensive treatment plan
   • weighing risks and alternatives
   • providing follow-up care.

Neglecting these steps could lead to medical board sanctions and suspension or revocation of a medical license.¹³

The blunt reality
We advise against recommending mari­juana for your patients. But if you have exhausted the alternatives, see marijuana as the last resort, and believe that taking the risk is worth the potential benefit, you can take some steps to reduce your legal risk (Table 2,^1,32,37,38 and Table 3¹³).

Bottom LinE
Medical marijuana is a controversial topic that demands more rigorous research and regulatory consideration. In the present climate, cautious physicians will avoid recommending marijuana to their patients. If you think that a patient has a medical indication, with no treatment option better than medical marijuana, be sure to understand the medical and legal ramifications before you authorize its use.

Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.